Evolving Models of Behavioral Health

7/30/2019 Evolving Models of Behavioral Health

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by Chris Collins, Denise Levis Hewson, Richard Munger, and Torlen Wade

Evolving Models of Behavioral HealthIntegration in Primary Care


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Evolving Models of Behavioral HealthIntegration in Primary Care

Milbank Memorial Fund

by Chris Collins, Denise Levis Hewson, Richard Munger, and Torlen Wade


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Milbank Memorial Fund

645 Madison Avenue

New York, NY 10022

The Milbank Memorial Fund is an endowed

operating foundation that engages in

nonpartisan analysis, study, research, and

communication on signicant issues in health

policy. In the Funds own publications, in

reports, lms, or books it publishes with other

organizations, and in articles it commissions

for publication by other organizations, the

Fund endeavors to maintain the highest

standards for accuracy and fairness.

Statements by individual authors, however,

do not necessarily reect opinions or factual

determinations of the Fund.

2010 Milbank Memorial Fund. All

rights reserved. This publication may be

redistributed electronically, digitally, or inprint for noncommercial purposes only as

long as it remains wholly intact, including this

copyright notice and disclaimer.

ISBN 978-1-887748-73-5


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Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

IntroductionMaking the Case for Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Orientation to the Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Practice Models of Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Practice Model 1: Improving Collaboration between Separate Providers . . . . . . . . . . . . . . . . .15

Practice Model 2: Medical-Provided Behavioral Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Practice Model 3: Co-location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Practice Model 4: Disease Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Practice Model 5: Reverse Co-location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Practice Model 6: Unied Primary Care and Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . 34

Practice Model 7: Primary Care Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Practice Model 8: Collaborative System of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Considerations for Choosing a Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Incremental Steps in a Challenging Fiscal Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

T A B L E O F C O N T E N T S


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Recommendations for Health Care Delivery System Redesign

to Support Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

C o n c l u s i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 0

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Selected Publications of the Milbank Memorial Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87


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Table 1: Four Quadrants of Clinical Integration Based on Patient Needs . . . . . . . . . . . . . . . . . . 8

Table 2: Using Information Technology to Integrate Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Table 3: Collaborative Care Categorizations at a Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Table 4: Examples of Practice Model 1Improving Collaboration

between Separate Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Table 5: Examples of Practice Model 2Medical-Provided Behavioral Health Care . . . . . . . . 20

Table 6: Examples of Practice Model 3Co-location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Table 7: Examples of Practice Model 4Disease Management . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Table 8: Examples of Practice Model 5Reverse Co-location . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Table 9: Examples of Practice Model 6Unied Primary Care

and Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Table 10: Examples of Practice Model 7Primary Care Behavioral Health . . . . . . . . . . . . . . . .41

Table 11: Examples of Practice Model 8Collaborative System of Care . . . . . . . . . . . . . . . . . . . 43

Table 12: Summary of Primary CareBehavioral Health Integration Models . . . . . . . . . . . . . 46

Table 13: Incremental Steps for Integrating Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

L I S T O F T A B L E S


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The U.S. mental health system fails to reach and/or adequately treat the millions of Americans

suffering from mental illness and substance abuse. This report offers an approach to meeting these

unmet needs: the integration of primary care and behavioral health care. The report summarizes

the available evidence and states experiences around integration as a means for delivering quality,

effective physical and mental health care. For those interested in integrating care, it provides

eight models that represent qualitatively different ways of integrating/coordinating care across

a continuumfrom minimal collaboration to partial integration to full integrationaccording to

stakeholder needs, resources, and practice patterns.

The Milbank Memorial Fund commissioned this report to provide policymakers with a primer

on integrated care that includes both a description of the various models along the continuum and a

useful planning guide for those seeking to successfully implement an integrated care model in their

jurisdiction.

The Milbank Memorial Fund is an endowed operating foundation that works to improve health

by helping decision makers in the public and private sectors acquire and use the best available

evidence to inform policy for health care and population health.

Policymakers, consultants, academicians, and practitioners knowledgeable in the eld reviewed

successive drafts of this report. As a result of these reviews and the authors subsequent revisions, we

believe that the information in this report is timely and accurate. We thank all who participated in

this project.

Carmen Hooker Odom

President

Samuel L. Milbank

Chairman

F O R E W O R D

Milbank Memorial Fund vi


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vii Milbank Memorial Fund

A C K N O W L E D G M E N T S

The following persons reviewed draft versions of this report. They are listed in the positions they held

at the time of their participation.

Harriette Chandler, Assistant Vice Chair, Senate Ways and Means Committee, Massachusetts Senate;

Gene Davis, Minority Whip, Utah Senate; Susanna Ginsburg, President, SG Associates Consulting;

Jack Hatch, Chair, Health and Human Services Appropriations Subcommittee, Iowa Senate; Brian

Hepburn, Executive Director, Mental Hygiene Administration, Maryland Department of Health and

Mental Hygiene; Anthony F. Lehman, Professor and Chair, Department of Psychiatry, University of

Maryland School of Medicine; Barbara J. Mauer, Managing Consultant, MCPP Healthcare Consulting;

Nancie McAnaugh, Deputy Director, Missouri Department of Health and Senior Services; Roy W.

Menninger, Chair, Kansas Mental Health Coalition; Marcia Nielsen, Executive Director, Kansas

Health Policy Authority; Douglas Porter, Assistant Secretary, Department of Social and Health

Services, Washington State Health and Recovery Services Administration; Charles K. Scott, Chair,

Labor, Health and Social Services Committee, Wyoming Senate; John Selig, Director, Arkansas

Department of Human Services; Betty Sims, former Missouri State Senator, Chair, Aging, Families

and Mental Health, Member, Missouri Mental Health Transformation Working Group; Beth Tanzman,

Deputy Commissioner, Vermont Department of Mental Health; and two anonymous reviewers.


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E X E C U T I V E S U M M A R Y

Mental illness impacts all age groups. The National Institute of Mental Health (NIMH) states in

a 2008 report that an estimated 26.2 percent of Americans ages eighteen and olderabout one in

four adultssuffer from a diagnosable mental disorder in a given year, which translates into 57.7

million people. Furthermore, researchers supported by NIMH have found that mental illness

begins very early in life (2005). Half of all lifetime cases begin by age fourteen, and three- quarters

have begun by age twenty-four. Thus, mental disorders are really the chronic diseases of the

young. Unfortunately, evidence also shows that the mental hea lth system fails to reach a signicant

number of people with mental illness, and those it does reach often drop out or get insufcient,

uncoordinated care.

The good news is that research has improved our ability to recognize, diagnose, and treat

conditions effectively. In fact, many studies over the past twenty-ve years have found correlations

between physical and mental health-related problems. Individuals with serious physical health

problems often have co-morbid mental health problems, and nearly half of those with any mental

disorder meet the criteria for two or more disorders, with severity strongly linked to co-morbidity

(Kessler et al. 2005). As cited in Robinson and Reiter (2007), as many as 70 percent of primar y

care visits stem from psychosocial issues. While patients typically present with a physical health

complaint, data suggest that underlying mental health or substance abuse issues are often triggering

these visits. Unfortunately, most primary care doctors are ill-equipped or lack the time to fully

address the wide range of psychosocial issues that are presented by the patients.

These realities explain why policymakers, planners, and providers of physical and behavioral

health care across the United States continue to grapple with how to deliver quality, effective mental

health services within the context of individual well-being and improved community health status.

Over the past several decades, examples of coordinated care service delivery modelsthose

that connect behavioral and physical healthhave led to promising approaches of integration and

collaboration. Emerging evidence from a variety of care models has stimulated the interest of

policymakers in both the public and private sectors to better understand the evidence underpinning

these models.

Improving the screening and treatment of mental health and substance abuse problems in

primary care sett ings and improving the medical care of individuals with serious mental health

problems and substance abuse in behavioral health settings are two growing areas of practice and

study. Generally, this combination of care is called integrationor collaboration.

Integrating mental health services into a primary care setting offers a promising, viable, and

efcient way of ensuring that people have access to needed mental health services. Additionally,mental health care delivered in an integrated setting can help to minimize stigma and

discrimination, while increasing opportunities to improve overall health outcomes. Successful

integration requires the support of a strengthened primary care delivery system as well as a long-

term commitment from policymakers at the federal, state, and private levels. This report assesses

models of integration in their applicability to primar y care settings and, in particular, to the

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medical home. Many of the challenges and barriers to integration stem from differing clinical

cultures, a fragmented delivery system, and varying reimbursement mechanisms.

This report also provides an orientation to the eld and, hopefully, a compelling case

for integrated or collaborative care. It provides a concise summary of the various models and

concepts and describes, in further detail, eight models that represent qualitatively different ways

of integrating and coordinating care across a continuumfrom minimal collaboration to partial

integration to full integration. Each model is dened and includes examples and successes, any

evidence-based research, and potential implementation and nancial considerations. Also provided

is guidance in choosing a model as well as specic information on how a state or jurisdiction could

approach integrated care through steps or tiers. Issues such as model complexity and cost are

provided to assist planners in assessing integration opportunities based on available resources and

funding. The report culminates with specic recommendations on how to support the successful

development of integrated care.

Extensive research and literature exist about models of integration. A resource section at the

end of this report provides a list of websites, toolkits, and other references.

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Despite positive changes and advancement in the treatment, support, and understanding of mental

illness over the past fty years, there is still need for improvement in the U.S. mental health care

system. Richard Frank and Sherry Glied demonstrate this need in their seminal workBetter But Not

Well(2006). They acknowledge that even though progress has been made in behavioral health care,

many people affected by mental illness are still very disadvantaged and not getting appropriate care.

There is increasing acknowledgment that mental health disorders are as disa bling as cancer

or heart disease in terms of lost productivity and premature death. A 2006, eight-state report by

Colton and Manderscheid documented that individuals with the most serious mental illnesses will

die twenty-ve years earlier than the average American. When mental illness is left untreated,

adults may experience lost productivity, unsuccessful relationships, signicant distress and

dysfunction, and/or an adverse impact in ca ring for children.

A comprehensive health care system must support mental health integration that treats the

patient at the point of care where the patient is most comforta ble and applies a patient-centered

approach to treatment. Integration is also important for positively impacting disparities in health

care in minority populations.

A 2008 report by Funk and Ivbijaro cited seven reasons for integrating mental health into

primary care. Each must be considered in any effort to design or implement a collaborative

approach, partial integration, or a fully integrated model.

1. The burden of mental disorders is great. Mental disorders are prevalent in all societies and

create a substantial personal burden for affected individuals and their families. They produce

signicant economic and social hardships that affect society as a whole.

2. Mental and physical health problems are interwoven. Many people suffer from both physical and

mental health problems. Integrated primary care helps to ensure that people are treated in a

holistic manner, meeting the mental health needs of people with physical disorders, as well as

the physical health needs of people with mental disorders.

3. The treatment gap for mental disorders is enormous. In all countries, there is a signicant gap

between the prevalence of mental disorders and the number of people receiving treatment and

care. Coordinating primary care and mental health helps close this divide.

4. Primary care settings for mental health services enhance access. When mental health is

integrated into primary care, people can access mental health services closer to their homes,

thus keeping families together and allowing them to maintain daily activities. Integration also

facilitates community outreach and mental health promotion, as well as long-term monitoringand management of affected individuals.

5. Delivering mental health services in primary care settings reduces stigma and discrimination.

6. Treating common mental disorders in primary care settings is cost-effective.

7. The majority of people with mental disorders treated in collaborative primary care have good outcomes,

particularly when linked to a network of services at a specialty care level and in the community.

I N T R O D U C T I O N M A K I N G T H E C A S E

F O R I N T E G R A T E D C A R E



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While there is growing awareness of the need for improved collaboration and integration, the

barriers to achieving them are substantial. Chief among these challenges are the following:

Behavioral and physical health providers have long operated in their separate silos. Sharing of information rarely occurs. Condentiality laws pertaining to substance abuse (federal and state) and mental health

(state) are generally more restrictive than those pertaining to physical health. While HIPAA

is often cited as a barrier to sharing information between primary care and mental health

practitioners, this is not accurate: sharing information for the purposes of care coordination

is a permitted activity under HIPAA, not requiring formal consents. However, many states

have mental health laws that are more restrictive and need to be reassessed. In regard to

federal regulation CFR 42, which restricts information sharing regarding substance abuse

services, there is currently a discussion under way to allow information sharing for the

purposes of treatment coordination. If this becomes new federal law, state laws will also need

to be changed to align with the new intent.

Payment and parity issues are prevalent.



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This report does not attempt to address the totality of issues in the eld of collaborative and

integrated care. Rather, it reects a robust and maturing literature that has been burgeoning in

recent years, including seminal work by more than a dozen prominent leaders, such as A lexander

Blount, Nicholas Cummings, Wayne Katon, Barbara Mauer, William ODonohue, C.J. Peek, Patricia

Robinson, and Kirk Strosahl.

In 2005, the Canadian Collaborative Mental Health Initiative (CCMHI) published a

comprehensive review of the literature (Pautler and Gagne). The CCMHI monograph analyzes the

entire research literature and includes a specic emphasis on randomized clinical tr ials (Craven

and Bland 2006). For states and jurisdictions seeking specic guidelines to implement integrated

programs, CCMHI, the Patient-Centered Primary Care Collaborative, and the New Zealand

Ministry of Health have published toolkits that offer practical advice on establishing integrated

initiatives (see the resources section). There are numerous technical review papers as well, covering

topics such as nancing and reimbursement, integrated models, rura l integrated care, and

assessment tools for state-level policymakers and others interested in integrating care.

Historically, innovative programs in collaboration and integration were rst developed in

settings like the Veterans Health Administration, federally qualied health centers (such as the

Cherokee Health Systems in East Tennessee), and health maintenance organizations (HMOs), such

as Kaiser Permanente. The Bureau of Primary Health Care within the U.S. Health Resources and

Services Administration (HRSA) has also supported a number of initiatives around the country.

Foundations such as the John A. Hartford Foundation, the John D. and Catherine T. MacArthur

Foundation, the Robert Wood Johnson Foundation, and the Hogg Foundation for Mental Health

have also funded projects that have helped dene the eld. Many of the projects have focused on

the treatment of depression in primary carean obvious choice because of depressions ubiquity in

the population. As of the writing of this report, there are at least two large-scale implementations

of integrated care: one in the U.S. Air Force and the other, the California Integrated Behavioral

Health Project. All of these integration efforts have contributed and continue to add signicantly

to the knowledge base in the eld.

While hundreds of integrated care initiatives are under way in the United St ates, there

is not a complete list or inventory of programs. A partial list , however, was compiled by the

U.S. government and is titled Compendium of Primary Care and Mental Health Integration

Activities across Various Participating Federal Agencies (Weaver 2008). There are also numerous

comprehensive clinical practice manuals that have been published, which offer suggestions on

the how to do it part of implementation, as well as websites with integrated care resources, twojournals covering t he eld, and a national membership organization on the subject. Finally, t here

are more than half a dozen inuential books that now document the basic concepts in the eld. All

of these documents and resources are cited in the resources section.

With such a vast amount of information in the eld, this report makes no effort to sy nthesize

it all. Rather, the report draws on some salient themes from the eldwith an eye to identifying


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practical implications for policymakers, planners, and providers of physical health and behavioral

health care.

D I F F E R E N C E S B E T W E E N C O L L A B O R A T I V E A N D I N T E G R A T E D C A R E

Primary careis described as the medical setting in which patients receive most of their medical care

and, therefore, is typically their rst source for treatment (Byrd, ODonohue, and Cummings 2005).

Primary care includes family medicine, general internal medicine, pediatrics, and sometimes

obstetrics-gynecology. Behavioral health careincludes both mental health and substance abuse

services. In the United States, the predominant behavioral health delivery model is specialty

behavioral health care, and it is delivered in separate behavioral health clinics. It is also common in

the United States to nd mental health and substance abuse services delivered in separate facilities.

Collaborative careand integrated careare the two terms most often used to describe the

interface of primary care and behavioral health care. Unfortunately, the terms collaborative care

and integrated careare not used consistently in the eld, and this has led to confusion. Strosahl

(1998) has proposed a basic dist inction that is useful. Namely, collaborative care involves behavioral

health workingwith primary care; integrated care involves behavioral health workingwithinand as

a part of primary care.

In collaborative care, patients perceive that they are getting a separate service from a specialist,

albeit one who collaborates closely with their physician. In integrated models, behavioral health

care is part of the primary care and patients perceive it as a routine part of their health care.

Integrated practice approaches are highly diverse; however, there are a number of broad concepts

that underlie the eld of collaborative and integrated care.

The granddaddy of theoretical viewpoints in the eld of collaborative and integrated care

is the biopsychosocial modelenunciated by Engel (1977). Simply stated, this model acknowledges

that biological, psychological, and social factors all play a signicant role in human functioning in

the context of disease. This model is endorsed by most medical professionals yet seldom practiced.

However, it is the theory at the root of collaborative and integrated care and is universally embraced

as a best practice.

C O N C E P T S C O M M O N T O A L L M O D E L S O F I N T E G R A T E D C A R E

There are four concepts common to all models of integrated care. Those concepts are the medicalhome, the health care team, stepped care, and the four-quadrant clinical integration.

The rst of the four concepts, the medical home, or health care home, has become a

mainstream theory in primar y care. It has also recently gained national attention in recognition

of its importance in caring for the chronically ill. The medical home concept is also one of the

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The National Committee for Quality Assurance (NCQA) has dened criteria for a medical home

the patient-centered medical homewhich includes standards that apply to disease and case

management activities that are benecial to both physical and mental health (2008). These criteria

include, but are not limited, to the following:

patient tracking and registry functions use of nonphysician staff for case management the adoption of evidence-based guidelines patient self-management support and tests (screenings) referral tracking

Most medical homes are compensated by a per-member-per -month (PMPM) fee, and

this fee could be enhanced if integrated physicalbehavioral health care is incorporated. (See

discussion of the Minnesota DIAMOND project in table 7.) While the concept of a medical home

is not specically an integrated behavioral health model, it clearly encompasses the phi losophy of

integration. Though not commonplace, a more dynamic role for behavioral health in the patient-

centered health care home has been recently dened (Mauer 2009).

The second concept common to all models of integrated care, t he health care team, is deeply

seated in the eld. In this approach, the doctor-patient relationship is replaced with a team-patient

relationship (Strosahl 2005). Applied to integrated care, members of the health care team share

responsibility for a patients care, and the message to the patient is that the team is responsible. A

visit is choreographed with various members of the team: physician, mid-level (nurse practitioner

or physicians assistant), nurse, care coordinator, behavioral health consultant, and other health

professionals. Blount (1998) notes that in a health care team each provider learns what the other

does and, in some cases, can ll in for one another.

The third concept, stepped care, is widely used in integrated care models. This concept holds

that, except for acutely ill patients, health care providers should offer care that (1) causes the least

disruption in the persons life; (2) is the least extensive needed for positive results; (3) is the least

intensive needed for positive results; (4) is the least expensive needed for positive results; and (5)

is the least expensive in terms of staff training required to provide effective service. In stepped

care, if the patients functioning does not improve through the usual course of care, the intensity

of service is customized according to the patients response. The rst step of behavioral care

involves basic educational efforts, such as sharing information and referral to self-help groups. Thesecond level steps up the care to involve clinicians who provide psycho-educational interventions

and make follow-up phone calls. The third level involves more highly trained behavioral health

care professionals who use specic practice algorithms. If a patient does not respond to these

progressions of care (or if specialized treatment is needed), the patient is then referred to the

specialty mental health system (Strosahl 2005). When referral to specialty care is necessary, there is



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acceptance that responsibility for some aspects of care should be retained by the primary care team,

which in turn will work colla boratively with the mental health provider. Sometimes, the patients

care can be transitioned back (or stepped down) fully to primary care after adequate specialty

mental health treatment/intervention has been provided.

The nal concept is referred to as four quadrant clinical integration, which identies

populations to be served in primary care versus specialty behavioral health. Different types of

services and organizational models are used depending on the needs of t he population in each

quadrant (Mauer 2006; National Council for Community Behavioral Healthcare 2009; Parks et al.

2005). This concept may also be used as a template for planning local health care systems. Table

1 summarizes the settings where an individual receives carebased on the complexity of his or her

physical and behavioral health needs.


Q U A D R A N T I I

Patients with high behavioral health and

low physical health needs

Served in primary care and specialty

mental health settings

(Example: patients with bipolar disorder

and chronic pain)Note: when mental health needs are

stable, often mental health care can be

transitioned back to primary care.

Q U A D R A N T I

Patients with low behavioral health and

low physical health needs

Served in primary care setting

(Example: patients with moderate alcohol

abuse and bromyalgia)

Q U A D R A N T I V

Patients with high behavioral health and

high physical health needs

Served in primary care and specialty

mental health settings

(Example: patients with schizophrenia

and metabolic syndrome or hepatitis C)

Q U A D R A N T I I I

Patients with low behavioral health and

high physical health needs

Served in primary care setting

(Example: patients with moderate

depression and uncontrolled diabetes)

T A B L E 1 : F O U R Q U A D R A N T S O F C L I N I C A L I N T E G R A T I O N B A S E D O NP A T I E N T N E E D S

LOW PH Y S I CA L H E A L T H R I S K /COMP L E X I T Y H I GH

Source: Adapted from Mauer 2006.

LOW

BEHAVIORALHEALTHRISK/CO

MPLEXITY

HIGH


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Patients in Quadrant I have low behavioral health needs and low physical needs and are

typically served in primary care. The physician may serve low-need patients with on-site behavioral

health staff serving those with low-to-moderate behavioral health needs. Quadrant II patients have

high behavioral health needs and low physical needs and are typically served in specialty behavioral

health programs with linkages to primary care. Patients in Quadrant III have low behavioral

health needs and high physical needs, and they are served in primary care or in the medical

specialty system. While this group is sometimes referred for specialty behavioral health care,

such care is usually short term. Ultimately, the responsibility for behavioral health care returns

to the primary care sett ing and is provided by behavioral health staff or disease case managers.

Quadrant IV patients have both high behavioral health needs and high physical needs. These

patients are typically served in both specialty behavioral health settings and primary care, with a

strong need for collaboration between the two. Patients in this quadrant have recently become a

targeted population given their predisposition to metabolic syndrome, particularly those patients

who are taking long-term psychoactive medications. (Metabolic syndrome includes elevated blood

pressure and cholesterol, obesity, and hyperglycemia.) Mauer (2006) has summarized some of the

characteristics of the Quadrant IV population:

lower medication adherence higher incidence of co-occurring chronic medical conditions high incidence of co-occurring alcohol and drug abuse problems lack of a stable medical home

more complex medical plans


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The use of information technology has great potential for designing and facilitating integration

efforts. Such technology can serve to support medical homes and providers in managing their target

populations and providing meaningful information that supports the best possible health care for

patients and their families. It can also provide client-level information that is relevant across providers

and delivery settings and can identify gaps in care as well as evidence-based best practice guidelines.

Table 2 illustrates half a dozen likely barriers to integration that can be resolved by using

information technology.

I N F O R M A T I O N T E C H N O L O G Y

I N T E G R A T I O N P R O B L E M T E C H N O L O G Y S O L U T I O N

1. A primary care practice

desires to make psychiatric

consultation available,

but psychiatric resources

are scarce and expensive.

2. A rural primary care

practice wants to

have psychiatric

consultation available.

3. A pediatric practice wants

to screen for mental health

issues and make accurate

diagnoses and referrals.

Numerous sites around the country are using telepsychiatry,

in which a psychiatrist uses remote computer technology to

interview and assess patients directly and either directly

provides treatment or provides consultation to the patients

primary care physician (Hilty et al. 2004).

An initiative in Canada pairs a primary care physician and a

psychiatrist, who share an email mentoring relationship.

The primary care physician exchanges emails about patients

with complex behavioral health needs, and the psychiatrist

provides advice. The ongoing consultation builds the skills

of the primary care physician (Pauze and Gagne 2005).

The Cleveland Coalition for Pediatric Mental Health has

developed a Web-based mental health resource guide,

accessible to local primary care providers, to enable

physicians to link families to appropriate resources. The

project includes a computerized interview to be completed

by parents and teenagers, which is then reviewed by the

physician to make a provisional diagnosis. The diagnosislinks to clinical guidelines and handouts/resources to share

with families (Edwards, Garcia, and Smith 2007).

(continued)


T A B L E 2 : U S I N G I N F O R M A T I O N T E C H N O L O G Y T O I N T E G R A T E C A R E


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I N T E G R A T I O N P R O B L E M T E C H N O L O G Y S O L U T I O N

4. Patient education handouts

for common psychological

issues are not effective.


serves a large indigent

population that struggles

with adherence to treatment

and attendance at follow-up

appointments.


wants to screen patients for

psychological issues with

limited staff.

Educational programs for a number of behavioral health

issues can be played on a patients iPod (see www.ipsyc.com).

The Health Buddy System gives patients a mini-computer-

like apparatus that connects to their telephone at home.

Each day, the Health Buddy displays questions about the

patients condition. The patient inputs his or her responses,

which are monitored by the primary care ofce via the

Internet. The Health Buddy can remind patients to take

medication and suggest self-management techniques.

Programs have been developed for a number of behavioral

health issues (see www.healthbuddy.com).

A computer-administered telephone version of PRIME-MD

(Primary Care Evaluation of Mental Disorders) provides

diagnostic information over the telephone through the use

of interactive voice response technology (Kobak et al. 1997).


T A B L E 2 ( CONT INUED )


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This report describes eight models of integration across a variety of settings. These models are

improved collaboration, medically provided behavioral health care, co-location, disease management,

reverse co-location, unied primary care and behavioral health, primary care behavioral health, and

collaborative system of care.

According to the Canadian Collaborative Mental Health Initiative (CCMHI), there are almost

as many ways of doing collaborative mental health care as there are people writing about it

(Macfarlane 2005, p. 11). As such, those who would like to integrate medical and behavioral health

care are confronted with a vast number of disparate interventions under the rubric of collaborative

care. This complexity is further compounded because most models are implemented as hybrids

and often blend together one or more elements of different models. And depending on the specic

implementation, a model may represent partial or full integration. Table 3 summarizes three basic

distinctions among collaborative models: coordinated, co-located, and integrated (Blount 2003).

Behavioral health care may be coordinatedwith primary care, but the actual delivery of services

may occur in different settings. As such, treatment (or the delivery of services) can be co-located(where

behavioral health and primary care are provided in the same location) or integrated, which means that

behavioral health and medical services are provided in one treatment plan. Integrated treatment plans

can occur in co-location and/or in separate treatment locations aided by Web-based health information

technology. Generally speaking, co-located care includes the elements of coordinated care, and

integrated care includes the elements of both coordinated care and co-located care.


P R A C T I C E M O D E L S O F I N T E G R A T I O N

C O O R D I N A T E D C O - L O C A T E D I N T E G R A T E D

Routine screening forbehavioral health

problems conducted in

primary care setting

Referral relationshipbetween primary care and

behavioral health settings

Routine exchange ofinformation betweenboth treatment settings to

bridge cultural differences

Medical services andbehavioral health

services located in the

same facility

Referral process formedical cases to be seen

by behavioral specialists

Enhanced informalcommunication betweenthe primary care provider

and the behavioral health

provider due to proximity

Medical services andbehavioral health services

located either in the same

facility or in separate

locations

One treatment planwith behavioral and medical

elements

Typically, a team workingtogether to deliver care,

using a prearranged protocol

(continued)

T A B L E 3 : C O L L A B O R A T I V E C A R E C A T E G O R I Z A T I O N S A T A G L A N C E


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This report identies eight practice models that represent qualitatively different ways of

integrating care. Following each model are examples of specic programs that illustrate these

differing approaches to care, and the descriptions of those programs can be found in tables 4

through 11. The descriptions are gleaned from reviews by Edwards, Garcia, and Smith (2007),

Koyanagi (2004), Lopez and colleagues (2008), and the National Council for Community Behavioral

Healthcare (2009). Readers are encouraged to consult these sources for a more in-depth analysis of

the programs. Also provided is a brief analysis of the evidence base for the model, but policymakers

and other planners might refer to the federal Agency for Healthcare Research and Qualitys

(AHRQ) comprehensive review of randomized controlled trial (RCT) studies of integrated care for

further information (Butler et al. 2008). Where available, additional information is provided on

implementation issues and challenges as well as nancial costs and considerations.

A helpful way to organize practice models is to look at the degree of integration along a

continuum. Doherty (1995) outlines a range of ve levels for mental health providers and primarycare to work togetherfrom the least to the highest degree of integration. A common level has been

assigned to each model in this report; however, depending on the specic implementation of a model,

the degree of collaboration varies. The ve levels are of integration are as follows:


C O O R D I N A T E D C O - L O C A T E D I N T E G R A T E D

Primary care providerto deliver behavioral health

interventions using brief

algorithms

Connections made betweenthe patient and resources

in the community

Source: Adapted from Blount 2003.

Consultation betweenthe behavioral health

and medical providers to

increase the skills of both

groups

Increase in the level andquality of behavioral health

services offered

Signicant reduction ofno-shows for behavioral

health treatment

Teams composed of aphysician and one or

more of the following:

physicians assistant, nurse

practitioner, nurse, case

manager, family advocate,

behavioral health therapist

Use of a database to trackthe care of patients who are

screened into behavioral

health services



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Minimal collaboration. Mental health providers and primary care providers work in separatefacilities, have separate systems, and communicate sporadically.

Basic collaboration at a distance. Primary care and behavioral health providers have separatesystems at separate sites, but now engage in periodic communication about shared patients.

Communication occurs typically by telephone or letter. Improved coordination is a step forward

compared to completely disconnected systems.

Basic collaboration on-site. Mental health and primary care professionals have separate systemsbut share the same facility. Proximity allows for more communication, but each provider

remains in his or her own professional culture.

Close collaboration in a partly integrated system. Mental health professionals and primarycare providers share the same facility and have some systems in common, such as scheduling

appointments or medical records. Physical proximity allows for regular face-to-face

communication among behavioral health and physical health providers. There is a sense of

being part of a larger team in which each professional appreciates his or her role in working

together to treat a shared patient.

Close collaboration in a fully integrated system. The mental health provider and primary careprovider are part of the same team. The patient experiences the mental health treatment as part

of his or her regular primary care.

As noted, many integrated programs around the country have combined elements of two or more of

the models. These blended programs are becoming more common than pure replications of the models

described because programs are often designed for a particular set of local or statewide circumstances,

such as target population, provider and service capacity, funding issues, and regulatory restrictions.

CO L L A BORA T I ON CON T I NUUM

M I N I M A L B A S I C B A S I C C L O S E C L O S E

a t a O n - s i t e P a r t l y F u l l y

D i s t a n c e I n t e g r a t e d I n t e g r a t e d


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In this model, providers practice separately and have separate administrative structures and

nancing/reimbursement systems. This model requires the least amount of change to traditional

practice, and, in many circumstances, it may be the only option available in the short run

(Koyanagi 2004).

A number of common strategies are used in this practice model. Case managers may be

assigned to coordinate health care for patients with complex physical health issues. A behavioral

health agency may offer psychiatric consultation via telephone to one or more primary care practices

that serve patients with complex medical issues. Information-sharing practices may be formalized,

such as adopting forms to share basic information (for example, a patients medication), so that

voluminous treatment records do not have to be sent.

E V I D E N C E B A S E

There are no randomized controlled trials using this model, and while anecdotal reports are mixed,

these kinds of approaches to improving collaboration may be useful rst steps as behavioral health

and primary care providers consider other integration opportunities.

I M P L E M E N T A T I O N C O N S I D E R A T I O N S

The cultural barriers in this practice model are signicant. Most primary care providers have not

developed the same relationships with community behavioral health providers as they have with

other specialty health providers, such as surgeons, cardiologists, or endocrinologists. Efforts need to

be made to develop those relationships so that providers can agree on communication and/or care

management strategies.

Privacy laws contribute to this isolated approach. To protect themselves from liability, mentalhealth agencies tend to default to the most restrictive state or federal law and apply that criterion to

all patients. This can make the sharing of clinical information very difcult.

Primary care providers often have limited knowledge about community agencies that can

provide valuable behavioral health services for their patients. Their willingness to invest time in

coordinating care will be inuenced by their past ability to access and communicate with specialty






P R A C T I C E M O D E L 1 : I M P R O V I N G C O L L A B O R A T I O N

B E T W E E N S E P A R A T E P R O V I D E R S


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mental health agencies. Primary care providers who are not systematically screening patients for

mental health and substance use have not developed a systematic approach to referral.

F I N A N C I A L C O N S I D E R A T I O N S

As long as state and federal condentiality laws remain rest rictive, agencies must have the staff and

the systems (paper or electronic) to track who provided consent, for what agency, for what purpose,

and for what length of time. Currently these tasks impose a signicant nancial burden with no

return to the agency or practice. Mental health and primary care providers generally do not have

the funding or resources required for the coordination of care, including providing consultations.

Options for consideration include the following:

Mental health case managers policy guidelines could be expanded to explicitly state that

activities involving coordination of care with primar y care providers allow for a billable case

management unit.


P R O G R A M S T A T E D E S C R I P T I O N

LifeWays

Washington

Medicaid

Integration

Partnership

Michigan

Washington

LifeWays, a nonprot behavioral health agency, has mental

health case managers who often transport patients to primary

care appointments. LifeWays has a formal policy stating

that mental health providers must contact referring primary

care providers. Administrative staff also meet annually with

large primary care practices to discuss ways to enhance

communication and address concerns (Koyanagi 2004).

Molina Healthcare is an HMO that receives a capitated

payment to provide physical and behavioral health care to

SSI clients. Molina provides care coordination across all

health care needs, including various mental health agencies,which submit written care plans. Care coordination

teams are led by RNs who also have access to psychiatric

consultation and mental health clinicians.

T A B L E 4 : E X A M P L E S O F P R A C T I C E M O D E L 1 I M P R O V I N G C O L L A B O R A T I O NB E T W E E N S E P A R A T E P R O V I D E R S


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As outlined in at least one state Medicaid progra m billing guide, the majority of Medicaidrecipients are assig ned a primary care provider (a medical home) through a primary care

case management (PCCM) model; an enhanced per member per month payment for the

coordination of care across the continuum is funded (North Ca rolina Division of Medical

Assistance 2009). This payment could be further enhanced to include the coordination for

specialty mental health and substance abuse (see the discussion of the Minnesota DIAMOND

project in table 7).



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Medical-provided behavioral health care is a delivery model in which only the medical providers are

directlyinvolved in service delivery. For example, there are simple things that physicians can do

to address behavioral health issues, such as discussing an exercise routine with depressed patients,

having patients use a daily log to plan some activities, or perhaps having a nurse to follow up with

the patient via a telephone call to ensure (or improve) medication compliance.

In this model, often consultation-liaisonis usedthe primary care provider delivers the

behavioral health service while receiving consultative support from a psychiatrist or other behavioral

health professional. The goal is to enhance the primary health care providers ability to treat

patients with behavioral health issues within a primary care setting. The psychiatrist works solely

as a consultant to the primary care provider, seeing patients with the physician or more commonly

advising via telephone, but not co-managing the patient.

To diagnose a behavioral health issue in a patient, primary care providers often use

evidence-based behavioral health screening tools. One such screening tool is the Patient Health

Questionnaire (PHQ-9) that is used to identify adults with depression (Kroenke and Spitzer 2002).

This nine-item questionnaire can be quickly completed, usually in one to two minutes. Ideally,

the physician conrms the depressive symptomology (by talking with patient, talking with other

providers, reviewing PHQ-9 scores, etc.) and then uses brief intervention algorithms for treatment.

Such practice is called screening and brief intervention (SBI). Many medical homes have begun to

integrate the screening of depression as a routine practice in caring for individuals with chronic

illnesses. This process may begin with a brief two-question screening, using the rst two questions

of the PHQ-9. Additionally, a growing number of primary care sites screen for multiple issues, such

as panic disorder, substance abuse, and even bipolar disorder. For children and adolescents, many

practices use the Pediatric Symptom Checklist as their global behavioral health screening tool

(Jellinek et al. 1988).

Brief intervention guidelines have been developed for most behavioral health issues that areseen in primary care (for example, see Hunter et al. 2009). In many cases, brief interventions can

be delivered directly by primary care physicians with minimal training. The American Academy of

Family Physicians (AAFP) has developed a number of algorithms for various disorders. Similarly,

the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the Ofce

of National Drug Control Policy have implemented Screening, Brief Intervention, Referral and






P R A C T I C E M O D E L 2 : M E D I C A L - P R O V I D E D B E H A V I O R A L

H E A L T H C A R E


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Treatment (SBIRT) programs. SBIRT interventions have been found to be effective in reducing

both the severity of mental health problems and the number of unnecessary emergency department

visits and hospitalizations (National Council for Community Behavioral Healthcare 2009).


There is a considerable evidence base for the effectiveness of SBI for substance abuse in primary care

settings (Trick and Nardini 2006), as well as for many common problems, including pain, smoking,

panic disorder, generalized anxiety, and depression (see sample studies in the resources section).

Nonetheless, primary care providers are more likely to screen for depression than for substance abuse.

This fact may reect their comfort level in the diagnostic and treatment process for substance abuse.


In implementing an SBI program, resistance may come from medical providers who voice concerns

about screening for behavioral health conditions in an already time-stretched medical appointment.

Concerns may also be based on discomfort with the skills needed to integrate mental health services,

particularly substance abuse services, into the practice. Resistance to screening may occur when

providers are unable to ensure access to behavioral health services and/or are unaware of the

local behavioral health resources available in the community. Consultation services will need to

be available, but those alone will not be sufcient to meet the needs of the patient. Primary care

providers may be reluctant to contact a psychiatrist with whom they have no prior professional

relationship. Opportunities to build those relationships, such as meet and greets, on-site lectures,

or clinical training (on how to get the most out of a consultation and/or stafng for patients with

complex conditions), can serve to increase comfort levels among primary care providers.

Patients identied through SBI as having complex mental health conditions are best treated

in specialty mental health and substance abuse agencies, not the primary care setting. So that the

primary care providers experiences in referring and coordinating care with these specialty agencies

are positive, there must be sufcient capacity within the community to support an easy transition

and coordination of care of the large variety of patients who are seen within the primary care setting.


To obtain nancial viability, practices will need to substantially increase their billing and coding

knowledge. Detailed coding information from the Current Procedural Terminology (CPT) of the

American Medical Association (AMA) (2009) is contained within the nancial considerations and

resources sections in this report. Often, providers are not aware of billing opportunities, are

unable to bill for two services on the same day, and nd reimbursement policy rules confusing. For


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example, Medicare authorizes brief interventions for alcohol and/or other substance abuse that can

be billed on t he same day as E/M (evaluation and management) codes, but providers must know that

a Medicare alpha code (G code) should be used for these services rather t han the codes created for

and used by private insurance.



National

Institute

on Alcohol

Abuse and

Alcoholism

Nationwide

Child

Psychiatry

Access Project

Massachusetts

The National Institute on Alcohol Abuse and Alcoholisms

brief intervention model has been sponsored in seventeen

states. SBI (screening and brief intervention) for substance

abuse in health care settings includes: (1) use of a screening

instrument to identify the problem; (2) brief intervention,

including motivational discussion and cognitive-behavioral

strategies; and (3) arrangements for follow-up care if

needed. The approach may be used by a primary care

physician, nurse practitioner, or other trained medical staff.

Typically, only a few hours of training are needed to deliver

the interventions successfully. A simple pocket guide

is available at http://pubs.niaaa.nih.gov/publications/

Practitioner/PocketGuide/pocket.pdf.

The University of Massachusetts has created a statewide

consultation model for primary care practices whereby

real-time telephone consultation is available from a child

psychiatrist or nurse specialist. The primary care physician

may also refer the patient for psychiatric evaluation and

assistance with treatment planning. A team composed of

a case manager, social worker, and psychiatrist provides

consultation and training for primary care physicians. The

team also helps families to access specialty care and offers

direct services if the family is put on a waiting list for

specialty services.

T A B L E 5 : E X A M P L E S O F P R A C T I C E M O D E L 2 M E D I C A L - P R O V I D E D B E H A V I O R A L

H E A L T H C A R E


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Telephone-based activities, including psychiatric consultations and brief patient follow-up

interventions, are generally not covered services. However, payment for telephone calls by a

physician to a patient for coordinating medical management with other health professionals may

be allowable when the calls have an impact on the medical treatment plan (AMA 2009 CPT codes

9937199373). Only the primary care provider can receive funding for the call. This means

the behavioral health provider has no existing payment mechanism for providing consultations.

Some state Medicaid programs are exploring the costs and benets of reimbursing for telephonic

consultation, and some jurisdictions have funded centralized phone consultations.



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Collaboration between mental health professionals and primar y care providers is likely to be more

effective when the clinicians are co-located and the location is familiar and nonstigmatizing for

patients. The co-location model uses specialty mental health clinicians who provide services at the

same site as primary care. This approach shares space but is run as a separate service. Patients

who present to a primary care provider with a medical complaint a nd are subsequently referred

to a mental health provider may resist the referral because it feels like therapy. Such resistance

could be due to the lingering stigma associated with needing therapy, and because traditional

counseling approaches are typically used, the interventions feel more like specialty care. Also,

when a behavioral health service is in a separate wing of the primary care site, there are fewer

opportunities for spontaneous contact with physicians, which may decrease patient willingness to

talk to a therapist. While co- location models are not fully integrated, physicians like them because

specialty mental health services are often difcult to access and having the service on-site is a

signicant step forward (Strosahl 2005). Co-located services do not guarantee integration, but they

are an important rst step.

Co-location models usually serve persons with less severe mental illnesses as compared to

specialty mental health settings. For example, persons with schizophrenia often require services

from an Assertive Community Treatment Team (ACTT) or a day rehabilitation program. However,

this practice model is effective with persons with serious but stable mental illnessproviding a

kind of mental health backup. The degree of collaboration varies widely in co-location models.

Opportunities for collaboration increase when there is the timely availability of a behavioral health

specialist to follow up on the primary care referral (Koyanagi 2004).

Positive implications of co-location include earlier identication, greater acceptance of referral,

and improved communication and care coordination. Shared plans of care can also signicantly

enhance the quality of care, prevent duplication of services, and reduce risk of adverse events.


Delivering specialty mental health in primary care settings produces greater engagement of patients

in mental health care, which is a prerequisite for better patient outcomes. Emerging literature on

co-located substance abuse treatment and primary care has shown that patients have better outcomes,






P R A C T I C E M O D E L 3 : C O - L O C A T I O N


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with the greatest improvement for those with poorer health (Craven and Bland 2006). Medical cost offset

may occur when patients use less medical care because they are receiving mental health services. The

reduced physical health care cost offsets the cost of the mental health care (Strosahl and Sobel 1996). And

diagnosis and treatment may signicantly improve in co-located models. This is attributed to behavioral

health clinicians taking an active role in teaching and coaching primary care providers (Koyanagi 2004).


The initial implementation issues are centered on the basic logistics of creating a successful

co-location model. The providers will need to address ofce space, consent forms, maintenance of

separate records, and staff roles and responsibilities in a co-located site. Behavioral health providers

who work in fty-minute windows may not be accessible to assist the primary care provider who

is working in a faster paced fteen-to-thirty-minute environment. When demand quickly exceeds

capacity, both organizations may experience frustration.

This practice model is primarily a referral-based process with providers working more closely

and with improved communications. As a general rule, patients must still migrate through a new

organization that could include separate appointment and intake processes. Having the mental

health service on-site will increase the primary care providers understanding of the referral process;

however, it may not improve the traditionally high patient no-show rates seen in mental health

without other support.


One of the strengths of this model is the physical proximity of providers. Medical providers are

encouraged to introduce the patient to the behavioral health provider at the time of the medical

appointment. These warm handoffs will work to decrease the number of no-shows but are

themselves not billable interactions. Once both providers have established a treatment relationship

and issues of consent have been addressed, the proximity can increase the exchange of relevant

clinical information; however, neither provider will be compensated for such informal consultations.

Each agency will, for nancial viability, need to limit and dene the scope of uncompensated services

that can be provided.

Patients may have limits on the number or cost of visits within both their physical and

behavioral health benet packages. In this model, a psychiatrist may use an evaluation andmanagement (E/M) code under a medical group number. If the payers billing system does not

correctly apply the visit, the primary care provider and psychiatrist can nd themselves competing

for a limited number of E/M visits under the medical health benets.



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Family

Medicine

Residencies

Nationwide

Armstrong

Pediatrics

Pennsylvania

The American Academy of Family Physicians has required

family medicine residencies to include behavioral health

training since the late 1960s. Since then, training sites around

the country have employed psychologists and social workers to

train physicians about the psychosocial aspects of health care.

Peek and Heinrich (1998) use the term ecology of careto refer

to the broader arena in which care must be managed and

collaboration must take place. The patient is viewed within a

family and life context. Behavioral health clinicians are

co-located at the primary care clinic. Behavioral health and

primary care providers have staff reviews of shared patients

and may conduct joint therapy sessions. This model increases

collaboration, but specialty mental health usually remains the

model of service delivery. The behavioral health provider is

typically viewed as an in-house specialist (Strosahl 2005).

Armstrong Pediatrics, a large rural primary care practice,

works with the nearby Western Psychiatric Institute and

Clinic in Pittsburgh to provide a range of mental health

services to youth. Children are screened for mental health

problems, and a nurse practitioner conducts assessments. A

social worker is available to provide on-site counseling, and a

psychiatrist is available for psychiatric evaluations and

consultations. About two-thirds of identied children need

treatment by only the physician or nurse practitioner. About

19 percent of identied children receive care from the social

worker or psychiatrist. Only 13 percent of identied children

require referral for specialty mental health care.(continued)

T A B L E 6 : E X A M P L E S O F P R A C T I C E M O D E L 3 C O - L O C A T I O N


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Washtenaw

Community

Health

Organization

Michigan The Washtenaw Community Health Organization is a

partnership between the county public mental health system

and the University of Michigan Health System. The

partnership allows for pooling of funds across systems and

shared risk. Mental health clinicians from the community

mental health center are out-stationed to primary care

practices to provide direct treatment. A psychiatrist

provides consultation to local public health clinics. The

project has added a reverse co-location initiative (see

discussion of Practice Model 5) by having a nurse

practitioner visit community mental health clinics to

provide primary care as well as to coordinate with the

patients physician if there is one.



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Psychological stress and disability accompany many chronic illnesses. The disease management (or

chronic care) model is an integrated system of interventions to optimize functioning of patients and

to impact the overall cost of the disease burden. The disease management model was developed

by Edward Wagner and his colleagues (2001). This practice model emphasizes both the early

identification in primary care of populations that are at risk for costly chronic disease (for example,

depression, diabetes, asthma) and the provision of educational orientation and evidence-based

algorithms (Mauer 2003). It is estimated that 60 percent of patients with chronic disorders do not

adhere to treatment regimens (Dunbar-Jacob and Mortimer-Stephens 2001), and this is especially true

for patients who live in poverty or in abusive familiesall circumstances that increase the difficulty of

caring for patients with chronic diseases.

A care manager provides follow-up care by monitoring the patients response and adherence to

treatment. The care manager also provides education to the patient about his or her disorder and self-

management strategies. Disease management models have an organized approach to assisting lifestyle

modification. Care managers may be nurses or masters-level social workers. These professionals may

provide brief psychotherapy if needed. Paraprofessionals, such as bachelors-level staff and LPNs, may

provide these services as well (following appropriate training).

The disease management model shares many similarities with the co-location model. The

distinction is that behavioral health interventions used in pure co-location models are typically

specialty mental health interventions that are brought into primary care. The emphasis in co-location

is using physical proximity to facilitate integration. The disease management model also involves

co-location, but the clinical interventions are typically modified for the primary care setting.

Another hallmark of the disease management model is the use of a patient registry, for example,

one that identifies all patients with chronic pain and depression. Special programming is targeted

for this population and patients are routinely monitored by a care manager to ensure that defined

interventions are completed.As noted earlier, the specific implementation of a model can change the level of integration, and

the disease management model in particular seems to roam across levels. Some programs operate

at either a basic level of collaboration (on-site) or at a close level of collaboration (partly integrated),

while others are similar to a close and fully integrated level (such as Practice Model 7, which is

discussed later) in which the care manager functions like a consultant/therapist.






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Three major philanthropic-funded initiatives have informed many disease management programs

around the country. In fact, these foundations have been responsible for much of the development of

integrated approaches over the past decade and, thus, are the reason that this practice model may be

the most prominent at the present time. These initiatives share numerous similarities but also have

unique implementations. Each has excellent websites and curriculum materials, and the IMPACT

program site (funded by the John A. Hartford Foundation) has a particularly impressive Web-based

training program. A brief synopsis of each initiative (gleaned from their respective websites) is

outlined below:

1. John A. Hartford Foundation InitiativeImproving Mood: Promoting Access to Collaborative

Treatment (IMPACT). This program, developed at the University of Washington, is a depression

management program based on a randomized controlled trial with a focus on older adults.

The patients primary care physician works with a care manager to develop and implement

a treatment plan (medications and/or brief, evidence-based therapy). The care manager and

primary care provider consult with a psychiatrist to change treatment plans if patients do not

improve. The care manager may be a nurse, social worker, or psychologist and may be supported

by a medical assistant or other paraprofessional. The model has recently been expanded to

include adolescents and the general adult population and to manage anxiety, substance abuse,

and other disorders in addition to depression.

2. MacArthur Foundation Initiative on Depression and Primary Care. This initiative uses a Three

Component Model: a trained physician and practice, a care manager, and a mental health

clinician, using a team-based approach. The care manager conducts regular telephone follow-up

calls to patients and keeps the physician informed about the patients progress. A standardized

assessment of depression severity is used. Psychiatric consultation is available to physicians.

3. Robert Wood Johnson Foundation (RWJF) InitiativeDepression in Primary Care: Linking Clinical

and System Strategies. The RWJF program is based on Edward Wagner and his colleagues

chronic care model and has many similarities to the MacArthur initiative. Additionally,

the project developed strategies to remove financial and structural barriers to integration.

Primary care providers were reimbursed to identify and manage depressed patients. The care

management function was funded to support physicians, as was a mental health clinician to

provide consultation.


Randomized controlled trials (RCTs) show that disease management models using care managers

are both clinically effective and cost-effective. Meta-analyses indicate that there is a cost offset of

20 to 40 percent for primary care patients who receive behavioral health services. Notably, fewer

hospitalizations result in significant cost reductions for patients with chronic physical illness and

those with psychiatric diagnoses (Blount et al. 2007).



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Disease management programs provide an opportunity to begin integrating the screening and

treatment or referral for behavioral health conditions. For implementing a disease management

model, the following considerations are noteworthy:

When implementing depression screening, providers need to understand that the depressionalgorithm is very aggressive over the first twelve weeks. The care manager/therapist providing

the service will need to be able to respond quickly to the referral and work in an integrated

fashion to support the primary care provider in the implementation of that algorithm.

Provider engagement and buy-in are essential, especially with the implementation of new clinicalguidelines for mental health conditions.

Practices engaged in disease management programs generally maintain a registry or database to

enable the identification of patients and the management of their disease. These systems need to

be able to support information and data for behavioral health processes as well. A comprehensive

disease management model should focus beyond single disease states of either physical or

behavioral health. A first step in that process would be to integrate behavioral health into the

existing medical disease management processes.


Medical disease management programs that incorporate new behavioral health screenings and clinical

pathways will require some additional resources. Options at the state level to provide needed funding

might include the following:

Expanding an existing medical home or primary care case management (PCCM) program toinclude patients with mental health and substance abuse disorders.

Expanding the role and funding for existing disease management programs. If providers arereimbursed on a fee-for-service basis, then consider that the following key disease management

activities are generally not reimbursed:

4 psychiatric consultations

4 outbound phone monitoring

4 coordination of care across the continuum

Reimbursing telephone-based interventions. Telephonic evaluation and management servicescan be reimbursed when meeting certain guidelineswhen provided by a physician (AMA 2009CPT codes 9944199443) or when provided by a qualified non-physician health care professional

(AMA 2009 CPT codes 9896698968).

As primary care providers adopt clinical pathways that are common within disease management

programs, the parity issue will be highlighted and begin to have a direct negative impact on their

reimbursement. Primary care providers who provide medical visits with mental health/substance



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abuse codes listed as the chief diagnosis may discover that the visit has a significantly higher patient

co-payment or may not be reimbursed at all. By 2014, the Medicare Improvements for Patients and

Providers Act (MIPPA) will require parity with co-payments. However, at the time this report is being

written, a publication by the Centers for Medicare and Medicaid Services, titledMedicare and Your

Mental Health Benefits (2007), states that approximately a 50 percent reduction in reimbursement

applies to outpatient treatment of a mental health condition.



Veterans

Health

Adminis-

tration (VHA)

Primary Care

Mental Health

Integration

Initiative

Aetna

Nationwide

Nationwide

The VHA is using two care management models in its health

clinics. One model uses a nurse care manager to provide

telephone monitoring to individuals with depression and

referral to specialty care when needed. The other model

uses a software-based assessment to determine three

interventions: watchful waiting, treatment by the primary

physician, and referral to specialty care. The VHA also is

co-locating behavioral health clinicians in health clinics.

The blending of both co-location and care management has

become the preferred model.

The Aetna Insurance Company is using a care management

model with persons with co-morbid conditions. Early

screening is used, and telephone psychiatric consultation is

available to primary care physicians. Care managers

monitor patients by telephone and refer patients to

behavioral health services as needed.

(continued)

T A B L E 7 : E X A M P L E S O F P R A C T I C E M O D E L 4 D I S E A S E M A N A G E M E N T


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Depression

Improvement

Across

Minnesota

Offering a

New Direction

(DIAMOND)

Inter-

mountain

Healthcare

Minnesota

Utah and

Idaho


This groundbreaking project is a partnership of medical

groups, health plans, the Department of Human Services, and

employer groups. The Hartford Foundations IMPACT model

is being used, featuring a care manager who provides ongoing

assessment, a patient registry, use of self-management

techniques, and the provision of psychiatric consultation.

Patient outcomes are far superior to results seen under the

usual care given currently to patients with depression in

primary care. The project is applying the concept of a case rate

payment for depression care. Minnesota health plans are

paying a monthly PMPM to participating clinics for a bundle

of servicesincluding the care manager and consulting

psychiatrist rolesunder a single billing code (Jaeckels 2009).

Intermountain Healthcare is a nonprot system that includes

outpatient clinics, hospitals, and health plans. Its Mental

Health Integration project began with the RWJF depression

initiative and has been expanded to include a focus on

evidence-based treatment algorithms. The program serves

both children and adults. After a comprehensive assessment,

patients are assigned to low care, which is managed by a

physician with support from a care manager, or moderate

care, which includes the entire team (mental health clinician

and psychiatric consultant). High-need patients are referred

to specialty carewith tools to facilitate communication and

follow-up with the mental health agency.


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Typically, integration is considered from the perspective of integrating behavioral health care into

primary care (Pincus 2004). However, the reversedapproach is also possible. The reverse co-location

model seeks to improve health care for persons with severe and persistent mental illness. Persons

with serious mental illness have high levels of medical co-morbidity compared to the general

population, as well as increased risk for diabetes, obesity, and high cholesterol due to the use of some

second-generation antipsychotic medications. Physical health care should be an essential service

for persons with serious mental illness. In the reverse co-location model, a primary care provider

(physician, physicians assistant, nurse practitioner, or nurse) may be out-stationed part- or full-

time in a psychiatric specialty setting to monitor the physical health of patients. Typical settings

are rehabilitation or day treatment programs, though services may also be viable in an outpatient

mental health clinic program. One variation of the model gives psychiatrists in mental health settings

additional medical training to monitor and treat common physical problems (Mauer and Druss 2007).

When a primary care provider is on-site at a facility that treats the severe and persistent mentally ill,

more time is available to address complex medical issues. Because they work in physical proximity, primary

care providers and behavioral health professionals develop strong collaborative relationships. The primary

care provider gains important experience with serious mental illness and may develop a keen ability to sort

out physical and behavioral symptoms. Finally, having primary care appointments and behavioral health

appointments on the same day in the same facility helps patients comply with treatment (Koyanagi 2004).


Studies of reverse co-location models are still in their infancy but have demonstrated the models

considerable potential to reduce lifestyle risk factors (Mauer and Druss 2007). For example, the

Massachusetts reverse co-location model described in table 8 lowered emergency room (ER) visits by

42 percent and dramatically increased screenings for hypertension and diabetes (Boardman 2006).


When a primary care provider is placed on-site at a mental health agency, some of the

implementation issues for reverse co-location will be similar to those of co-location. Providers will






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